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Locatelli F, Zugmaier G, Rizzari C, Morris JD, Gruhn B, Klingebiel T, Parasole R, Linderkamp C, Flotho C, Petit A, Micalizzi C, Mergen N, Mohammad A, Kormany WN, Eckert C, Möricke A, Sartor M, Hrusak O, Peters C, Saha V, Vinti L, von Stackelberg A. Effect of Blinatumomab vs Chemotherapy on Event-Free Survival Among Children With High-risk First-Relapse B-Cell Acute Lymphoblastic Leukemia: A Randomized Clinical Trial. JAMA 2021; 325:843-854. [PMID: 33651091 PMCID: PMC7926287 DOI: 10.1001/jama.2021.0987] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Blinatumomab is a CD3/CD19-directed bispecific T-cell engager molecule with efficacy in children with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL). OBJECTIVE To evaluate event-free survival in children with high-risk first-relapse B-ALL after a third consolidation course with blinatumomab vs consolidation chemotherapy before allogeneic hematopoietic stem cell transplant. DESIGN, SETTING, AND PARTICIPANTS In this randomized phase 3 clinical trial, patients were enrolled November 2015 to July 2019 (data cutoff, July 17, 2019). Investigators at 47 centers in 13 countries enrolled children older than 28 days and younger than 18 years with high-risk first-relapse B-ALL in morphologic complete remission (M1 marrow, <5% blasts) or with M2 marrow (blasts ≥5% and <25%) at randomization. INTERVENTION Patients were randomized to receive 1 cycle of blinatumomab (n = 54; 15 μg/m2/d for 4 weeks, continuous intravenous infusion) or chemotherapy (n = 54) for the third consolidation. MAIN OUTCOMES AND MEASURES The primary end point was event-free survival (events: relapse, death, second malignancy, or failure to achieve complete remission). The key secondary efficacy end point was overall survival. Other secondary end points included minimal residual disease remission and incidence of adverse events. RESULTS A total of 108 patients were randomized (median age, 5.0 years [interquartile range {IQR}, 4.0-10.5]; 51.9% girls; 97.2% M1 marrow) and all patients were included in the analysis. Enrollment was terminated early for benefit of blinatumomab in accordance with a prespecified stopping rule. After a median of 22.4 months of follow-up (IQR, 8.1-34.2), the incidence of events in the blinatumomab vs consolidation chemotherapy groups was 31% vs 57% (log-rank P < .001; hazard ratio [HR], 0.33 [95% CI, 0.18-0.61]). Deaths occurred in 8 patients (14.8%) in the blinatumomab group and 16 (29.6%) in the consolidation chemotherapy group. The overall survival HR was 0.43 (95% CI, 0.18-1.01). Minimal residual disease remission was observed in more patients in the blinatumomab vs consolidation chemotherapy group (90% [44/49] vs 54% [26/48]; difference, 35.6% [95% CI, 15.6%-52.5%]). No fatal adverse events were reported. In the blinatumomab vs consolidation chemotherapy group, the incidence of serious adverse events was 24.1% vs 43.1%, respectively, and the incidence of adverse events greater than or equal to grade 3 was 57.4% vs 82.4%. Adverse events leading to treatment discontinuation were reported in 2 patients in the blinatumomab group. CONCLUSIONS AND RELEVANCE Among children with high-risk first-relapse B-ALL, treatment with 1 cycle of blinatumomab compared with standard intensive multidrug chemotherapy before allogeneic hematopoietic stem cell transplant resulted in an improved event-free survival at a median of 22.4 months of follow-up. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02393859.
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Affiliation(s)
- Franco Locatelli
- IRCCS Ospedale Pediatrico Bambino Gesù and Sapienza University of Rome, Rome, Italy
| | | | | | | | | | | | - Rosanna Parasole
- Azienda Ospedaliera di Rilievo Nazionale Santobono Pausilipon, Naples, Italy
| | | | | | - Arnaud Petit
- Sorbonne Université, Hôpital Armand Trousseau, AP-HP, Paris, France
| | | | | | | | | | | | - Anja Möricke
- Universitätsklinikum Schleswig–Holstein, Kiel, Germany
| | - Mary Sartor
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Ondrej Hrusak
- Charles University, Motol University Hospital, Prague, Czech Republic
| | | | - Vaskar Saha
- The University of Manchester, Manchester, United Kingdom
- Tata Translational Cancer Research Center, Tata Medical Center, Kolkata, West Bengal, India
| | - Luciana Vinti
- IRCCS Ospedale Pediatrico Bambino Gesù and Sapienza University of Rome, Rome, Italy
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Topp MS, Gökbuget N, Zugmaier G, Klappers P, Stelljes M, Neumann S, Viardot A, Marks R, Diedrich H, Faul C, Reichle A, Horst HA, Brüggemann M, Wessiepe D, Holland C, Alekar S, Mergen N, Einsele H, Hoelzer D, Bargou RC. Phase II Trial of the Anti-CD19 Bispecific T Cell–Engager Blinatumomab Shows Hematologic and Molecular Remissions in Patients With Relapsed or Refractory B-Precursor Acute Lymphoblastic Leukemia. J Clin Oncol 2014; 32:4134-40. [DOI: 10.1200/jco.2014.56.3247] [Citation(s) in RCA: 482] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Patients with relapsed or refractory acute lymphoblastic leukemia (ALL) have a dismal prognosis. CD19 is homogenously expressed in B-precursor ALL and can be targeted by the investigational bispecific T cell–engager antibody blinatumomab. A phase II trial was performed to determine clinical activity in this patient cohort. Patients and Methods Thirty-six patients with relapsed or refractory B-precursor ALL were treated with blinatumomab in cycles of 4-week continuous infusion followed by a 2-week treatment-free interval in a single-arm study with a dose-finding stage and an extension stage. The primary end point was complete remission (CR) or CR with partial hematologic recovery (CRh). Major secondary end points included minimal residual disease (MRD) response, rate of allogeneic hematopoietic stem-cell transplantation (HSCT) realization, relapse-free survival (RFS), overall survival (OS), and incidence of adverse events (AEs). Results Median age was 32 years (range, 18 to 77 years). Twenty-five patients (69%) achieved a CR or CRh, with 88% of the responders achieving an MRD response. Median OS was 9.8 months (95% CI, 8.5 to 14.9), and median RFS was 7.6 months (95% CI, 4.5 to 9.5). Thirteen responders (52%) underwent HSCT after achieving a CR or CRh. The most frequent AE during treatment was pyrexia (grade 1 or 2, 75%; grade 3, 6%). In six patients with nervous system or psychiatric disorder AEs and in two patients with cytokine release syndrome, treatment had to be interrupted or discontinued. These medical events were resolved clinically. Conclusion The data support further investigation of blinatumomab for the treatment of adult patients with relapsed or refractory ALL in a larger confirmatory study.
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Affiliation(s)
- Max S. Topp
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Nicola Gökbuget
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Gerhard Zugmaier
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Petra Klappers
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Matthias Stelljes
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Svenja Neumann
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Andreas Viardot
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Reinhard Marks
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Helmut Diedrich
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Christoph Faul
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Albrecht Reichle
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Heinz-August Horst
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Monika Brüggemann
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Dorothea Wessiepe
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Chris Holland
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Shilpa Alekar
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Noemi Mergen
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Hermann Einsele
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Dieter Hoelzer
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
| | - Ralf C. Bargou
- Max S. Topp, Hermann Einsele, and Ralf C. Bargou, Universitätsklinikum Würzburg, Würzburg; Nicola Gökbuget, Goethe University; Dieter Hoelzer, Onkologikum, Frankfurt; Gerhard Zugmaier, Petra Klappers, and Noemi Mergen, Amgen Research; Dorothea Wessiepe, Metronomia, Munich; Matthias Stelljes, University of Münster, Münster; Svenja Neumann, Heinz-August Horst, and Monika Brüggemann, University Schleswig Holstein, City Hospital, Kiel; Andreas Viardot, University of Ulm, Ulm; Reinhard Marks,
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